Vaginal bleeding is common in the first trimester (0 to 13+6 weeks), occurring in 20 to 40% of pregnant women. It may be any combination of light or heavy, intermittent or constant, painless or painful. The five major sources of non-traumatic bleeding in early pregnancy are: ectopic pregnancy; early pregnancy loss; implantation of the pregnancy; threatened abortion; and cervical, vaginal, or uterine pathologies (e.g., polyps, inflammation/infection, gestational trophoblastic disease).
An ectopic pregnancy is an extrauterine pregnancy most commonly presenting with at least one missed menstrual cycle, vaginal bleeding, nausea, abdominal pain, and/or pre-syncopal symptoms.
A ruptured ectopic pregnancy occurs at 6 to 10 weeks gestation and presents with severe or persistent abdominal pain associated with syncope, hypotension, shoulder tip pain (Kehr’s sign), rebound tenderness, or guarding.
Miscarriage, also called a spontaneous abortion or early pregnancy loss, is defined as a non-viable intrauterine pregnancy up to 20 weeks gestation. The majority of miscarriages occur in the first trimester. Spontaneous abortions are common but a distressing complication of pregnancy. Common signs and symptoms associated with the condition are abdominal pain or cramping and vaginal bleeding.
Essentials
All patients with suspected ectopic pregnancy must be conveyed to hospital, regardless of the severity of their presentation or response to management.
Patients experiencing potential spontaneous abortions may present with the following signs:
Abdominal or pelvic pain/cramping. Pain may radiate to lower back, buttocks, or genitals.
Vaginal bleeding may be present and can range from spotting to life threatening hemorrhage. Depending on gestation and the nature of the miscarriage, the patient may pass the product of conception.
Rapid conveyance of unstable patients to surgically capable ED is essential.
Any woman of childbearing age with any of the following symptoms should be considered as presenting with a ruptured ectopic pregnancy until proven otherwise:
abdominal pain
vaginal bleeding
shock or syncope
Unstable patients should be managed in accordance with CPG D01: Shock.
Consider using abdominal pads to estimate blood loss en route to ED.
There is no diagnostic procedure or specific management of miscarriage in the out-of-hospital environment. Management should focus on emotional support of the patient and treatment of symptoms such as pain and nausea. Paramedics and EMRs/FRs should always keep a high index of suspicion for life threatening complications, such as major hemorrhage or ectopic pregnancy.
Referral Information
All patients with suspected ectopic pregnancy or spontaneous abortion must be conveyed to the closest and most appropriate facility, regardless of the severity of their presentation or response to management.
General Information
Ectopic pregnancies occur in 1-2% of all pregnancies and are caused by the developing embryo implanting outside the uterus. The vast majority (over 98%) of ectopic pregnancies are located within the fallopian tubes. Worldwide, the incidence of ectopic pregnancy is rising; this has been attributed to a variety of risk factors, including:
In vitro fertilization and fertility treatments
Sexually transmitted illnesses (e.g., chlamydia and gonorrhea)
Pelvic inflammatory disease
Use of intrauterine devices
Advanced maternal age
Tubal damage from previous surgeries
Endometriosis
Bleeding in pregnancy should be evaluated based on gestational age of the fetus and the characteristics of the bleeding (light vs. heavy, painful vs. painless, intermittent vs. constant).
Patients may pass products of conception which can range in nature from blood clots to a recognizable fetus. In the event of preterm labour in the second trimester, delivery may proceed spontaneously. The fetus may initially make small movements or gasp. While an infant delivered at greater than 20 weeks gestation must be registered as a birth from a legal perspective, there is no prospect for successful resuscitation prior to 23 weeks gestation. It is reasonable for paramedics and EMRs/FRs to withhold resuscitation; this decision should be explained to the patient in a sensitive way.
Regardless of appearance or gestation, the fetus may be important to the patient. Do not dispose of the fetus. Treat the fetus respectfully in accordance with the patient’s wishes. If necessary, clamp and cut the umbilical cord. Paramedics and EMRs/FRs should wrap the fetus and convey it with the patient. Products of conception are generally sent to pathology for further examination. The patient or other family members may wish to hold the fetus. This should be supported as the patient or other family members often feel comforted by the fact that the fetus was held after the dying process.
Many women experience a strong sense of loss, sadness, anger, disbelief, disappointment, sense of isolation, and often guilt. It is normal to experience a range of feelings. Paramedics and EMRs/FRs should acknowledge the impact of the miscarriage with compassion and understanding. Minimizing the loss of the pregnancy can significantly worsen the patient’s experience.
Ambulance Victoria. Clinical Practice Guidelines: Ambulance and MICA Paramedics. 2018. [Link]
Roberts I, et al. The CRASH-2 trial: A randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. 2013. [Link]
Stovall TG et al. Emergency department diagnosis of ectopic pregnancy. 1990. [Link]
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): An international, randomised, double-blind, placebo-controlled trial. 2017. [Link]